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One size does not fit all: adapt and localise for effective, proportionate and equitable responses to COVID-19 in Africa

One size does not fit all: adapt and localise for effective, proportionate and equitable... Open access Commentary One size does not fit all: adapt and localise for effective, proportionate and equitable responses to COVID-19 in Africa 1 1 2 Hayley MacGregor , Melissa Leach, Akhona Tshangela, 1 3 4 3 Tabitha A Hrynick , Shelley Lees , Eva Niederberger, Melissa Parker, 1 3 1 4 Santiago Ripoll Lorenzo , Hana Rohan, Megan Schmidt- Sane, Olivia Tulloch, Annie Wilkinson To cite: MacGregor H, Leach M, INTRODUCTION political and economic pressures necessitated Tshangela A, et al. One The heterogeneous epidemiological picture an easing of ‘lockdowns’ as 2020 progressed. size does not fit all: adapt for COVID-19 in Africa continues to generate More limited measures are evident in situa- and localise for effective, debate. Modelling projections raise spec- tions where cases of community transmission proportionate and equitable responses to COVID-19 in ulation about the phases and trends of of SARS- CoV-2 and deaths have risen as some Africa. Fam Med Com Health SARS- CoV-2 outbreaks across the continent countries face a second wave. All of these 2021;9:e000709. doi:10.1136/ and how these differ from outbreaks else- factors, alongside the paucity of resources, fmch-2020-000709 1–4 where. Continental efforts drew praise lack of definitive pharmacological treatments Received 25 August 2020 in the first wave of COVID-19, and success and likely delays in deployment of vaccines Revised 11 February 2021 has been linked to African experience of on the continent, have further intensified Accepted 22 February 2021 epidemics and to decisive leadership. Yet the the need for context-appropriate public tendency at the outset of the pandemic with health and social measures, tailored to ensure initial responses to the threat of COVID-19 proportionality of responses as differing was for African governments to look to stan- scenarios unfold. dard models emphasising central control, We contend that a critical part of adapta- following the WHO and partly mirroring tion and proportionality is a localisation of the stringent restrictions as already deployed response that builds on people’s own inven- in Asia and Europe. The negative effects of tiveness and the knowledge and experience ‘lockdowns’ and a vertical, disease-specific of local organisations. Drawing on knowl- ‘health security’ response on livelihoods, edge exchange webinars run collaboratively food security and healthcare for other condi- between the Africa Centres for Disease tions have threatened to overshadow the Control and the Social Science in Humani- direct suffering and even mortality engen- 5 tarian Action Platform in 2020, we consider dered by COVID-19 alone. These effects positive examples of adaption that have © Author(s) (or their have been evident also in high- income coun- emerged. We present a preliminary typology employer(s)) 2021. Re- use tries but manifested rapidly and intensely in permitted under CC BY. of important domains for localisation of Africa. This scenario highlights the problems Published by BMJ. public health and social measures, with a 1 of generic approaches to response given Institute of Development focus on interventions to protect people very different settings in which a pandemic Studies, Brighton, UK who are vulnerable—socially, economically, Africa Centres for Disease unfolds, suggesting that further attention politically and also biologically. We call for Control and Prevention, African should have been paid by decision makers Union, Addis Ababa, Ethiopia acknowledgement of the importance of to significant adaptation to African realities Department of Global Health local- level responses and the need to support from the start. The continent is also hugely and Development, London these and for the establishment of fora to diverse in health system and social protec- School of Hygiene & Tropical share learning about adaptation and effec- Medicine, London, UK tion capacities, demographics and popula- Anthrologica, Oxford, UK tive models. Streamlined funding mecha- tion density, underscoring an argument for nisms that allow for rapid flow of resources to adaptation and contextualised responses Correspondence to support initiatives ‘from below’ also need to across African settings. Moreover, since the Dr Hayley MacGregor; h. macgregor@ ids. ac. uk initial imposition of extensive curtailment, be strengthened. MacGregor H, et al. Fam Med Com Health 2021;9:e000709. doi:10.1136/fmch-2020-000709 1 Open access Table 1 Typology of Adaptive Responses with selected examples Domain Example of intervention Mitigating hardship Livelihoods in the informal Burkina Faso announced support for informal sector workers, as did Egypt and Tunisia. In economy Namibia, South Africa and Zimbabwe one- off or temporary cash grants have been provided to vulnerable people. Coverage depends on the strength of social protection systems and on access to mobile phones (for cash transfers), ID cards or inclusion in state databases. https:// www.wiego.org/government-responses-covid-19-crisis Food insecurity Community Action Networks investigate the most appropriate ways to provide food relief for the hungry in Cape Town, South Africa. https://theconversation.com/local-networks-can-help- people-in-distress-south-africas-covid-19-response-needs-them-138219 Food markets Urban municipal government in Bo, Sierra Leone, works with local researchers to identify hygiene and physical distancing measures in a busy open market to enable it to stay open safely. https://africanarguments.org/2020/03/30/preparing-for-covid-19-in-africa/. Care of the ill Home care for COVID-19 Amref has partnered with governments to provide training on the safe provision and support of homecare for COVID-19 to community health workers via the Leap app, which works on simple mobile phones. https://newsroom.amref.org/blog/2020/08/building-health-worker-capacity-on- home-based-care-and-isolation-using-digital-learning-in-kenya/ Protecting the medically vulnerable Shielding the clinically Shielding is informally underway in Ethiopia, where community society groups and non- vulnerable governmental organisations provide food, infection prevention and basic economic support to the shielded. https://gh.bmj.com/content/5/7/e003204.info Maintaining essential The International Community of Women Living with HIV West Africa has partnered with healthcare healthcare facilities to recruit a cadre of ‘community pharmacists’ to home deliver treatments for HIV and other conditions in Nigeria and Côte d’Ivoire. https://www.unaids.org/en/resources/ presscentre/featurestories/2020/july/20200714_arv-cotedivoire-nigeria Preventing transmission Local information An existing network of residents has organised monitoring and ‘situation tracking’ of COVID-19 in informal settlements in Nairobi in order to liaise with the city government about service provision and the local situation, with assistance of community health volunteers. https://www. muungano.net/muunganos-covid-19-response Dialogue and trust In Kivu, DRC, members of the Amani Institute, a sociocultural movement, have worked with youth volunteers who visit public spaces and homes of internally displaced persons to share information about COVID-19 prevention. https://amani-institute.org/2020/05/04/coronavirus-in- a-context-of-conflicts-and-humanitarian-crisis-in-eastern-drcongo/ Burials Traditional leaders in South Africa’s Eastern Cape have reintroduced ukuqhusheka or ‘secret burials’, a historic funerary practice with cultural significance that limits the number of people who attend bodies and burials. https://www.bbc.co.uk/news/world-africa-52571862 Isolation of those who are Slum and Shack Dwellers International Kenya has provided input to the Department of Health’s positive guidelines for Isolation Centres, taking account of conditions in informal settlements. https:// www.muungano.net/browseblogs/2020/6/11/covid-19-muungano-alliance-contributes-to- government-guidelines-on-isolation-centers Screening, testing and In South Africa, cadres of community healthcare workers were deployed early for community- contact tracing level screening and referral for testing, using skills gained in combating HIV and tuberculosis. https://www.ft.com/content/98d0d7c6-9bfb-4a64-bcab-19e0854a3b4d Hygiene provision Handwashing stations have been installed in places with limited water infrastructure, for example, informal settlements in Kenya and Rwanda. In Sudan, community committees made and distributed their own sanitisers. https://blogs.worldbank.org/nasikiliza/innovations-time- covid-19-rising-pandemics-challenges-africas-informal-settlements The politics of easing restrictions: balancing public health preparedness and response are not neutral, scientific action against the impacts of measures processes but deeply political and social as well. Deci- The current dilemmas faced by African governments— sion makers are inevitably influenced by politics and as elsewhere—bring to the fore the reality that epidemic economics, in addition to scientific data. Indeed, amidst 2 MacGregor H, et al. Fam Med Com Health 2021;9:e000709. doi:10.1136/fmch-2020-000709 Open access the great scientific and societal uncertainty that an emer- isolation and community- based care to prevalent reali- gent pathogen generates, it may be politically easier to ties such as multi-occupancy in crowded dwellings or the pursue standardised routes of preparedness and response, absence of running water. which prioritise containment through top-down, disease- As restrictions ease for general publics, a further key specific, state-led inter ventions. The political responses question is how to protect those particularly vulnerable across African countries have been complex and diverse to COVID-19. Strategies may include developing practi- and reflect national and geopolitical tensions, as else- cable means for ‘shielding’ the clinically vulnerable in where. Definitive ‘lockdowns’ can have political meaning multigenerational households, medication delivery for and even gain for governments that wish to be seen the chronically ill to reduce exposure or food and cash to act swiftly and take strong control in a crisis. In the relief for those who are suffering economically. extreme, some have been accused of using the pandemic In this respect, initiatives developed at community to legitimate excessively authoritarian responses. Strin- level, led by a range of local actors, are likely to be a vital gent measures might have delayed outbreaks initially or aspect of localisation and adaptation of standardised even contained them in some contexts, but the secondary outbreak response guidelines. The 2013–2016 West Africa impacts on economies, livelihoods and health have neces- Ebola outbreak provided clear evidence that local- level sitated a weighing up of the relative effects of an outbreak action can be significant in turning epidemics around. surge against those of the restrictions. These decisions For example, citizens applied insights and past experi- have become even more difficult as several African coun- ence of disease control to protect themselves and to tries have experienced a second wave of COVID-19 that arrange safe burials and morally acceptable care of kin. has proven to be more deadly than the first and as muta- Harnessing mobilisation, knowledge and inventiveness tions have increased transmissibility of the virus. ‘on the ground’ and hearing from local people about In May, Africa CDC issued guidance on the easing of their priorities, or concerns about other prevalent health restrictions while warning also that it was likely Africa would and livelihood issues, is key to a proportionate and effec- yet become a frontier of the pandemic with community tive response that people understand and trust. Local transmission increasing in some countries. These appar- organisations can document conditions, such as inequali- ently paradoxical messages highlighted that such easing, ties in availability of services, and provide access to a spec- too, involved consideration of political and economic trum of information that can be vital for moving forward factors as well as epidemiological ones—the lifting of effectively. This can include epidemiologically relevant lockdowns in Africa became necessary to save lives, econ- reports, given the lack of testing or recording of deaths omies and livelihoods, as was made explicit in the launch in some settings. Localisation can also enable a response of an African Union campaign ‘Africa against COVID-19’ that is attentive to social differences and vulnerabilities. in mid- August 2020. Social and economic vulnerability on the continent is exacerbated by high reliance on informal A typology of emerging locally adaptive responses economic activity and on local markets for food, a lack At this juncture, it is critical to share learning widely. To of social protection safety nets and living conditions this end, we have distilled emerging domains for inter- in densely populated and poorly serviced urban settle- ventions, drawn from our knowledge and presented in a ments where physical distancing, isolation and hygiene preliminary typology of adapted responses with localised measures are difficult to achieve. Sustaining livelihoods examples (table 1). This table is not exhaustive but envis- is ultimately linked to saving lives but easing restrictions aged as an illustrative starter on a range of adapted alterna- also saves lives more directly. In addition to food insecu- tives, so that these can be documented and disseminated. rity causing malnutrition, the prioritisation of responses to COVID-19 has disrupted essential health services, such Supporting interconnections between state-led responses and as for immunisation and care of other prevalent diseases. mobilisation ‘on the ground’ Contributing factors include issues of supply (disruption A range of actors have been involved in localised inter- of flows of drugs and equipment, illness or redeployment ventions, including community- based and faith- based of staff) and access (lack of transport to reach services and other non- governmental organisations and the and fear of breaching restrictions). private sector, sometimes in partnership with central government, local authorities or international agencies. One size does not fit all: adaptation and localisation of Other initiatives involve networks and federations, such responses is key as of informal settlement residents, or civil society groups. These realities point to a strong argument for responses Furthermore, local organisation by those with informal that are adapted and proportionate to local contexts authority can help in a crisis like COVID-19, as indeed and epidemiology. With the easing of more extreme occurred with Ebola in West Africa. Limitations in containment measures, national- level interventions for government capacities highlight the importance of coor- reducing community transmission that minimise impact dinated activity between state responses and those ‘from on broader aspects of socioeconomic well-being have below’, and interconnections and synergies between local become more important. At local levels, it has become experience and action, and government- led public health necessary to adapt physical distancing, hand washing, responses. The nature of existing governance structures MacGregor H, et al. Fam Med Com Health 2021;9:e000709. doi:10.1136/fmch-2020-000709 3 Open access Science in Humanitarian Action Platform executive gave input into the argument can help determine which actors are best placed to coor- and commented on text (TAH, SL, EN, MP, SRL, HR, MS- S, OT and AW) and text for dinate efforts. Community-based actors with recognised examples in the table (AW, EN, TAH, SRL and OT). Contribution from this group has local authority can act as key interlocutors and improve been equal, and they are listed after HM and ML in alphabetical order. dialogue and trust. Funding This study was funded by Wellcome Trust and DFID 219169/Z/19/Z. In arguing for adaptation and localisation, we are Competing interests None declared. not proposing that the lion’s share of responsibility for Patient consent for publication Not required. preventing community transmission, mitigating socioeco- Provenance and peer review Not commissioned; externally peer reviewed. nomic impacts or protecting the vulnerable should fall on ‘communities’ or that responsibility to reduce infection Open access This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits risk should be construed as located with individuals alone. others to copy, redistribute, remix, transform and build upon this work for any When extensive state- enforced restrictions are eased, it is purpose, provided the original work is properly cited, a link to the licence is given, easy for governments to resort to transferring responsibility and indication of whether changes were made. See: https:// creativecommons. org/ for preventing infections to individuals or local leaders. This licenses/ by/ 4. 0/. is especially problematic in contexts characterised by struc- ORCID iDs tural violence and where people’s living conditions make Hayley MacGregor http:// orcid. org/ 0000- 0002- 9392- 9331 public health measures challenging to meet. It can lead to Tabitha A Hrynick http:// orcid. org/ 0000- 0001- 9571- 5874 Shelley Lees http:// orcid. org/ 0000- 0003- 0062- 7930 the blaming of groups and individuals who are marginal- Santiago Ripoll Lorenzo http:// orcid. org/ 0000- 0002- 1735- 0432 ised, further intensifying inequalities that COVID-19 has laid bare. National, municipal and local authorities have important roles to play in partnering with community and REFERENCES grassroots groups to support and enable their efforts. Local- 1 Twahirwa Rwema JO, Diouf D, Phaswana- Mafuya N, et al. level action can play a further role in holding the state to COVID-19 across Africa: epidemiologic heterogeneity and necessity account, if the political environment is favourable. of Contextually relevant transmission models and intervention strategies. Ann Intern Med 2020;173:752–3. 2 Mbow M, Lell B, Jochems SP, et al. COVID-19 in Africa: dampening the storm? Science 2020;369:624–6. 3 Nordling L. The pandemic appears to have spared Africa so far. CONCLUSION scientists are struggling to explain why, 2020. Available: https:// Response plans for epidemics that privilege top-down action www. sciencemag. org/ news/ 2020/ 08/ pandemic- appears- have- spared- africa- so- far- scientists- are- struggling- explain- why? utm_ have been the norm, and governments have frequently source= Nature+ Briefing& utm_ campaign= b6db6ce366- briefing- echoed restrictive measures for COVID-19 as implemented dy- 20200813& utm_ medium= email& utm_ term= 0_ c9dfd39373- b6db6ce366- 45179894 [Accessed Aug 2020]. in other global regions. For African countries, mounting 4 Maeda JM, Nkengasong JN. The puzzle of the COVID-19 pandemic evidence of deleterious effects of stringent approaches has in Africa. Science 2021;371:27–8. 5 Tony Blair Institute for global change. COVID-19 in Africa – and Africa led to growing acknowledgement of their limitations, and beyond COVID-19, 2020. Available: https:// institute. global/ sites/ of the necessity for a diversity of responses, given also epide- default/ files/ inline- files/ Tony% 20Blair% 20Institute% 2C% 20Covid- miological heterogeneity. Various responses are emerging 19% 20and% 20Africa% 20and% 20Africa% 20Beyond% 20Covid- 19% 2C% 20May% 202020v2. pdf as decision makers in different countries adapt guidelines 6 An African plan to control COVID-19 is urgently needed. Lancet and pursue particular strategies, according to their social, 2020;396:1777. 7 Leach M, MacGregor H. Pandemic preparedness: who is being economic and political contexts, as well as their histories and prepared for what and by whom? 2019;29 https://www. ids. ac. uk/ past disease experiences. Greater appreciation by scientists opinions/ pandemic- preparedness- who- is- being- prepared- for- what- and policymakers of this diversity and its contextual shaping and- by- whom/ 8 MacGregor H, Ripoll S, Leach M. Disease Outbreaks: Navigating by factors that extend beyond epidemiology and public uncertainties in Preparedness and Response. In: Scoones I, Stirling health need alone, is badly needed. We argue that it is also A, eds. The politics of uncertainty. Abingdon: Routledge, 2020. 9 Smith J, Cheeseman N. itarians are exploiting the coronavirus. necessary to pay serious attention to initiatives that adapt Democracies must not follow suit. Foreign Policy 2020;28 https:// measures at the local level, led by a range of actors and even foreignpolicy. com/ 2020/ 04/ 28/ authoritarians- exploiting- coronavirus- emerging ‘from below’. This can assist in attuning inter-undermine- civil- liberties- democracies/ 10 Massinga Loembé M, Tshangela A, Salyer SJ, et al. COVID-19 in ventions to different contextual realities and in ensuring Africa: the spread and response. Nat Med 2020;26:999–1003. that they are proportionate, attentive to vulnerabilities and 11 Barasa E, Mothupi MC, Guleid F. Health and socio-economic impacts of physical distancing for COVID-19 in Africa. KEMRI-W ellcome Trust social inequalities and socially just. We have shared some Research Programme and African Academy of Sciences, 2020. emergent positive examples that could be built on but this 12 Wilkinson A, Ali H, Bedford J, et al. Local response in health emergencies: key considerations for addressing the COVID-19 requires political will. These initiatives have been at the pandemic in informal urban settlements. Environ Urban margins and urgently need to be brought in more centrally 2020;32:503–22. and given greater recognition and resourcing, both from 13 Chi Y-L, Regan L, Nemzof f C. Beyond COVID-19: a whole of health look at impacts during the pandemic response. policy paper 177. national and international sources. Improving interconnec- Center for Global Development 2020 https://www. cgdev. org/ tions between responses ‘from above’ and ‘from below’ will publication/ beyond- covid- 19- whole- health- look- impacts- during- pandemic- response be critical in moving forward. 14 Dahab M, van Zandvoort K, Flasche S. Conflict and health 2020;14. 15 Richards P. Ebola: how a people’s science helped end an epidemic. Contributors The commentary was drafted by HM, and HM and ML did the initial London: Zed Books, 2016. conceptualisation. Further conceptual and written input was given by AT of the 16 Parker M, Hanson TM, Vandi A, et al. Ebola and public authority: Africa Centres for Disease Control and Prevention. The members of the Social saving Loved ones in Sierra Leone. Med Anthropol 2019;38:440–54. 4 MacGregor H, et al. Fam Med Com Health 2021;9:e000709. doi:10.1136/fmch-2020-000709 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Family Medicine and Community Health British Medical Journal

One size does not fit all: adapt and localise for effective, proportionate and equitable responses to COVID-19 in Africa

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British Medical Journal
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© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.
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2305-6983
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2009-8774
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10.1136/fmch-2020-000709
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Abstract

Open access Commentary One size does not fit all: adapt and localise for effective, proportionate and equitable responses to COVID-19 in Africa 1 1 2 Hayley MacGregor , Melissa Leach, Akhona Tshangela, 1 3 4 3 Tabitha A Hrynick , Shelley Lees , Eva Niederberger, Melissa Parker, 1 3 1 4 Santiago Ripoll Lorenzo , Hana Rohan, Megan Schmidt- Sane, Olivia Tulloch, Annie Wilkinson To cite: MacGregor H, Leach M, INTRODUCTION political and economic pressures necessitated Tshangela A, et al. One The heterogeneous epidemiological picture an easing of ‘lockdowns’ as 2020 progressed. size does not fit all: adapt for COVID-19 in Africa continues to generate More limited measures are evident in situa- and localise for effective, debate. Modelling projections raise spec- tions where cases of community transmission proportionate and equitable responses to COVID-19 in ulation about the phases and trends of of SARS- CoV-2 and deaths have risen as some Africa. Fam Med Com Health SARS- CoV-2 outbreaks across the continent countries face a second wave. All of these 2021;9:e000709. doi:10.1136/ and how these differ from outbreaks else- factors, alongside the paucity of resources, fmch-2020-000709 1–4 where. Continental efforts drew praise lack of definitive pharmacological treatments Received 25 August 2020 in the first wave of COVID-19, and success and likely delays in deployment of vaccines Revised 11 February 2021 has been linked to African experience of on the continent, have further intensified Accepted 22 February 2021 epidemics and to decisive leadership. Yet the the need for context-appropriate public tendency at the outset of the pandemic with health and social measures, tailored to ensure initial responses to the threat of COVID-19 proportionality of responses as differing was for African governments to look to stan- scenarios unfold. dard models emphasising central control, We contend that a critical part of adapta- following the WHO and partly mirroring tion and proportionality is a localisation of the stringent restrictions as already deployed response that builds on people’s own inven- in Asia and Europe. The negative effects of tiveness and the knowledge and experience ‘lockdowns’ and a vertical, disease-specific of local organisations. Drawing on knowl- ‘health security’ response on livelihoods, edge exchange webinars run collaboratively food security and healthcare for other condi- between the Africa Centres for Disease tions have threatened to overshadow the Control and the Social Science in Humani- direct suffering and even mortality engen- 5 tarian Action Platform in 2020, we consider dered by COVID-19 alone. These effects positive examples of adaption that have © Author(s) (or their have been evident also in high- income coun- emerged. We present a preliminary typology employer(s)) 2021. Re- use tries but manifested rapidly and intensely in permitted under CC BY. of important domains for localisation of Africa. This scenario highlights the problems Published by BMJ. public health and social measures, with a 1 of generic approaches to response given Institute of Development focus on interventions to protect people very different settings in which a pandemic Studies, Brighton, UK who are vulnerable—socially, economically, Africa Centres for Disease unfolds, suggesting that further attention politically and also biologically. We call for Control and Prevention, African should have been paid by decision makers Union, Addis Ababa, Ethiopia acknowledgement of the importance of to significant adaptation to African realities Department of Global Health local- level responses and the need to support from the start. The continent is also hugely and Development, London these and for the establishment of fora to diverse in health system and social protec- School of Hygiene & Tropical share learning about adaptation and effec- Medicine, London, UK tion capacities, demographics and popula- Anthrologica, Oxford, UK tive models. Streamlined funding mecha- tion density, underscoring an argument for nisms that allow for rapid flow of resources to adaptation and contextualised responses Correspondence to support initiatives ‘from below’ also need to across African settings. Moreover, since the Dr Hayley MacGregor; h. macgregor@ ids. ac. uk initial imposition of extensive curtailment, be strengthened. MacGregor H, et al. Fam Med Com Health 2021;9:e000709. doi:10.1136/fmch-2020-000709 1 Open access Table 1 Typology of Adaptive Responses with selected examples Domain Example of intervention Mitigating hardship Livelihoods in the informal Burkina Faso announced support for informal sector workers, as did Egypt and Tunisia. In economy Namibia, South Africa and Zimbabwe one- off or temporary cash grants have been provided to vulnerable people. Coverage depends on the strength of social protection systems and on access to mobile phones (for cash transfers), ID cards or inclusion in state databases. https:// www.wiego.org/government-responses-covid-19-crisis Food insecurity Community Action Networks investigate the most appropriate ways to provide food relief for the hungry in Cape Town, South Africa. https://theconversation.com/local-networks-can-help- people-in-distress-south-africas-covid-19-response-needs-them-138219 Food markets Urban municipal government in Bo, Sierra Leone, works with local researchers to identify hygiene and physical distancing measures in a busy open market to enable it to stay open safely. https://africanarguments.org/2020/03/30/preparing-for-covid-19-in-africa/. Care of the ill Home care for COVID-19 Amref has partnered with governments to provide training on the safe provision and support of homecare for COVID-19 to community health workers via the Leap app, which works on simple mobile phones. https://newsroom.amref.org/blog/2020/08/building-health-worker-capacity-on- home-based-care-and-isolation-using-digital-learning-in-kenya/ Protecting the medically vulnerable Shielding the clinically Shielding is informally underway in Ethiopia, where community society groups and non- vulnerable governmental organisations provide food, infection prevention and basic economic support to the shielded. https://gh.bmj.com/content/5/7/e003204.info Maintaining essential The International Community of Women Living with HIV West Africa has partnered with healthcare healthcare facilities to recruit a cadre of ‘community pharmacists’ to home deliver treatments for HIV and other conditions in Nigeria and Côte d’Ivoire. https://www.unaids.org/en/resources/ presscentre/featurestories/2020/july/20200714_arv-cotedivoire-nigeria Preventing transmission Local information An existing network of residents has organised monitoring and ‘situation tracking’ of COVID-19 in informal settlements in Nairobi in order to liaise with the city government about service provision and the local situation, with assistance of community health volunteers. https://www. muungano.net/muunganos-covid-19-response Dialogue and trust In Kivu, DRC, members of the Amani Institute, a sociocultural movement, have worked with youth volunteers who visit public spaces and homes of internally displaced persons to share information about COVID-19 prevention. https://amani-institute.org/2020/05/04/coronavirus-in- a-context-of-conflicts-and-humanitarian-crisis-in-eastern-drcongo/ Burials Traditional leaders in South Africa’s Eastern Cape have reintroduced ukuqhusheka or ‘secret burials’, a historic funerary practice with cultural significance that limits the number of people who attend bodies and burials. https://www.bbc.co.uk/news/world-africa-52571862 Isolation of those who are Slum and Shack Dwellers International Kenya has provided input to the Department of Health’s positive guidelines for Isolation Centres, taking account of conditions in informal settlements. https:// www.muungano.net/browseblogs/2020/6/11/covid-19-muungano-alliance-contributes-to- government-guidelines-on-isolation-centers Screening, testing and In South Africa, cadres of community healthcare workers were deployed early for community- contact tracing level screening and referral for testing, using skills gained in combating HIV and tuberculosis. https://www.ft.com/content/98d0d7c6-9bfb-4a64-bcab-19e0854a3b4d Hygiene provision Handwashing stations have been installed in places with limited water infrastructure, for example, informal settlements in Kenya and Rwanda. In Sudan, community committees made and distributed their own sanitisers. https://blogs.worldbank.org/nasikiliza/innovations-time- covid-19-rising-pandemics-challenges-africas-informal-settlements The politics of easing restrictions: balancing public health preparedness and response are not neutral, scientific action against the impacts of measures processes but deeply political and social as well. Deci- The current dilemmas faced by African governments— sion makers are inevitably influenced by politics and as elsewhere—bring to the fore the reality that epidemic economics, in addition to scientific data. Indeed, amidst 2 MacGregor H, et al. Fam Med Com Health 2021;9:e000709. doi:10.1136/fmch-2020-000709 Open access the great scientific and societal uncertainty that an emer- isolation and community- based care to prevalent reali- gent pathogen generates, it may be politically easier to ties such as multi-occupancy in crowded dwellings or the pursue standardised routes of preparedness and response, absence of running water. which prioritise containment through top-down, disease- As restrictions ease for general publics, a further key specific, state-led inter ventions. The political responses question is how to protect those particularly vulnerable across African countries have been complex and diverse to COVID-19. Strategies may include developing practi- and reflect national and geopolitical tensions, as else- cable means for ‘shielding’ the clinically vulnerable in where. Definitive ‘lockdowns’ can have political meaning multigenerational households, medication delivery for and even gain for governments that wish to be seen the chronically ill to reduce exposure or food and cash to act swiftly and take strong control in a crisis. In the relief for those who are suffering economically. extreme, some have been accused of using the pandemic In this respect, initiatives developed at community to legitimate excessively authoritarian responses. Strin- level, led by a range of local actors, are likely to be a vital gent measures might have delayed outbreaks initially or aspect of localisation and adaptation of standardised even contained them in some contexts, but the secondary outbreak response guidelines. The 2013–2016 West Africa impacts on economies, livelihoods and health have neces- Ebola outbreak provided clear evidence that local- level sitated a weighing up of the relative effects of an outbreak action can be significant in turning epidemics around. surge against those of the restrictions. These decisions For example, citizens applied insights and past experi- have become even more difficult as several African coun- ence of disease control to protect themselves and to tries have experienced a second wave of COVID-19 that arrange safe burials and morally acceptable care of kin. has proven to be more deadly than the first and as muta- Harnessing mobilisation, knowledge and inventiveness tions have increased transmissibility of the virus. ‘on the ground’ and hearing from local people about In May, Africa CDC issued guidance on the easing of their priorities, or concerns about other prevalent health restrictions while warning also that it was likely Africa would and livelihood issues, is key to a proportionate and effec- yet become a frontier of the pandemic with community tive response that people understand and trust. Local transmission increasing in some countries. These appar- organisations can document conditions, such as inequali- ently paradoxical messages highlighted that such easing, ties in availability of services, and provide access to a spec- too, involved consideration of political and economic trum of information that can be vital for moving forward factors as well as epidemiological ones—the lifting of effectively. This can include epidemiologically relevant lockdowns in Africa became necessary to save lives, econ- reports, given the lack of testing or recording of deaths omies and livelihoods, as was made explicit in the launch in some settings. Localisation can also enable a response of an African Union campaign ‘Africa against COVID-19’ that is attentive to social differences and vulnerabilities. in mid- August 2020. Social and economic vulnerability on the continent is exacerbated by high reliance on informal A typology of emerging locally adaptive responses economic activity and on local markets for food, a lack At this juncture, it is critical to share learning widely. To of social protection safety nets and living conditions this end, we have distilled emerging domains for inter- in densely populated and poorly serviced urban settle- ventions, drawn from our knowledge and presented in a ments where physical distancing, isolation and hygiene preliminary typology of adapted responses with localised measures are difficult to achieve. Sustaining livelihoods examples (table 1). This table is not exhaustive but envis- is ultimately linked to saving lives but easing restrictions aged as an illustrative starter on a range of adapted alterna- also saves lives more directly. In addition to food insecu- tives, so that these can be documented and disseminated. rity causing malnutrition, the prioritisation of responses to COVID-19 has disrupted essential health services, such Supporting interconnections between state-led responses and as for immunisation and care of other prevalent diseases. mobilisation ‘on the ground’ Contributing factors include issues of supply (disruption A range of actors have been involved in localised inter- of flows of drugs and equipment, illness or redeployment ventions, including community- based and faith- based of staff) and access (lack of transport to reach services and other non- governmental organisations and the and fear of breaching restrictions). private sector, sometimes in partnership with central government, local authorities or international agencies. One size does not fit all: adaptation and localisation of Other initiatives involve networks and federations, such responses is key as of informal settlement residents, or civil society groups. These realities point to a strong argument for responses Furthermore, local organisation by those with informal that are adapted and proportionate to local contexts authority can help in a crisis like COVID-19, as indeed and epidemiology. With the easing of more extreme occurred with Ebola in West Africa. Limitations in containment measures, national- level interventions for government capacities highlight the importance of coor- reducing community transmission that minimise impact dinated activity between state responses and those ‘from on broader aspects of socioeconomic well-being have below’, and interconnections and synergies between local become more important. At local levels, it has become experience and action, and government- led public health necessary to adapt physical distancing, hand washing, responses. The nature of existing governance structures MacGregor H, et al. Fam Med Com Health 2021;9:e000709. doi:10.1136/fmch-2020-000709 3 Open access Science in Humanitarian Action Platform executive gave input into the argument can help determine which actors are best placed to coor- and commented on text (TAH, SL, EN, MP, SRL, HR, MS- S, OT and AW) and text for dinate efforts. Community-based actors with recognised examples in the table (AW, EN, TAH, SRL and OT). Contribution from this group has local authority can act as key interlocutors and improve been equal, and they are listed after HM and ML in alphabetical order. dialogue and trust. Funding This study was funded by Wellcome Trust and DFID 219169/Z/19/Z. In arguing for adaptation and localisation, we are Competing interests None declared. not proposing that the lion’s share of responsibility for Patient consent for publication Not required. preventing community transmission, mitigating socioeco- Provenance and peer review Not commissioned; externally peer reviewed. nomic impacts or protecting the vulnerable should fall on ‘communities’ or that responsibility to reduce infection Open access This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits risk should be construed as located with individuals alone. others to copy, redistribute, remix, transform and build upon this work for any When extensive state- enforced restrictions are eased, it is purpose, provided the original work is properly cited, a link to the licence is given, easy for governments to resort to transferring responsibility and indication of whether changes were made. See: https:// creativecommons. org/ for preventing infections to individuals or local leaders. This licenses/ by/ 4. 0/. is especially problematic in contexts characterised by struc- ORCID iDs tural violence and where people’s living conditions make Hayley MacGregor http:// orcid. org/ 0000- 0002- 9392- 9331 public health measures challenging to meet. It can lead to Tabitha A Hrynick http:// orcid. org/ 0000- 0001- 9571- 5874 Shelley Lees http:// orcid. org/ 0000- 0003- 0062- 7930 the blaming of groups and individuals who are marginal- Santiago Ripoll Lorenzo http:// orcid. org/ 0000- 0002- 1735- 0432 ised, further intensifying inequalities that COVID-19 has laid bare. National, municipal and local authorities have important roles to play in partnering with community and REFERENCES grassroots groups to support and enable their efforts. 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Journal

Family Medicine and Community HealthBritish Medical Journal

Published: Apr 2, 2021

Keywords: health policypublic healthsocial determinants of healthglobal health

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